Basic Information
| Provider Information | |||||||||
| NPI: | 1073517058 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROOSEVELT COUNTY SPECIAL HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ROOSEVELT GENERAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 868 | ||||||||
| Address2: | |||||||||
| City: | PORTALES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 881300868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753591800 | ||||||||
| FaxNumber: | 5753569200 | ||||||||
| Practice Location | |||||||||
| Address1: | 42121 US HIGHWAY 70 | ||||||||
| Address2: | |||||||||
| City: | PORTALES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 881309357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753591800 | ||||||||
| FaxNumber: | 5753569200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 04/15/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOYER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5753563416 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 3061 | NM | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 148185501 | 05 | TX | MEDICAID | 148185503 | 05 | TX | MEDICAID | 17678 | 01 | PRESBYTERIAN SALUD/HOSPIT | OTHER | G8765 | 05 | NM | MEDICAID | G8786 | 01 | MEDICAID/PHYSICIANS | OTHER | NM007684 | 01 | BCBS/PHYSICIANS | OTHER | 23587 | 01 | LOVELACE SALUD/HOSPITAL | OTHER | NM000077 | 01 | BCBS/HOSPITAL | OTHER | 148185502 | 05 | TX | MEDICAID | 23587 | 01 | LOVELACE SALUD/PHYSICIANS | OTHER | G8465 | 05 | NM | MEDICAID |